United States District Court Violation Notice
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1United States District Court
CVB Location Code
Violation Notice
1
Violation Number
Officer Name (Print)
Officer No.
2
3
4
YOU ARE CHARGED WITH THE FOLLOWING VIOLATION
Date and Time of Offense (mm/dd/yyy) Offense Charged
CFR
USC
State Code
6
5
Place of Offense
7
Offense Description
8
9
DEFENDANT INFORMATION
Phone:(
)
Offense Description
First Name
M.I.
10
11
12
Street Address
13
City
State
Zip Code
Date of Birth (mm/dd/yyyy)
14
15
16
17
Driver’s License No.
D.L. State Social Security No.
18
19
20
21
22
Hair
Height
Eyes
Weight
23
24
25
26
Adult
Juvenile Sex
Male
Female
27
VEHICLE DESCRIPTION
VIN:
Tag No.
State
Year
Make/Model
Color
28
29
30
31
32
A
IF BOX A IS CHECKED, YOU
B
IF BOX A IS CHECKED, YOU MUST
MUST APPEAR IN COURT,
PAY AMOUNT INDICATED BELOW
SEE
INSTRUCTIONS (on back of yellow copy)
OR APPEAR IN COURT.
SEE INSTRUCTIONS (on back of yellow copy)
33
34
Forfeiture Amount
+ $25.00 Processing Fee
PAY THIS AMOUNT
$
Total Collateral Due
YOUR COURT DATE
(If no court appearance date is shown, you will be notified of your appearance date by mail.)
Date (mm/dd/yyyy)
Court Address
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35
Time (hh:mm)
37
My signature signifies that I have received a copy of this violation notice. It is not an admission of guilt.
I promise to appear for the hearing at the time and place instructed or pay the total collateral due.
38
X Defendant Signature
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